Iredell-Statesville Schools

VOLUNTEER PROFILE FORM

Iredell Statesville Schools have developed a volunteer/chaperone screening process to help ensure the safety of our children.

·  School Level Volunteers will complete section 1 and 2 of this form and return it to the school principal at least 7 days before they begin their volunteer work on campus.

·  Level 2 Volunteers as well as chaperones for overnight field trips must complete section 1, 2, and 3 of this form. A background check is required for chaperones. A school check in the amount of $25.00/chaperone, payable to Iredell-Statesville Schools, must be returned to I-SS Central Support (Attn: Human Resources) thirty (30) days prior to trip date. You may read a copy of School Board Policy 3320 by visiting our website (www.iss.k12.nc.us).

Section 1: Volunteer Contact Information

First Name ______Middle/Maiden ______Last Name

Home Address, City, State, Zip

Home Phone______Cell Phone______E-mail Address

Employer Business Phone

Business Address, City, State, Zip

Have you ever been employed by I-SS? Yes No If yes, give dates of employment:

For Field Trips Only:

Destination of Trip______School______Grade______

Student Name______Contact Person for Trip______

Section 2: References

Please print. Complete the following information for three non-family references.

1.  Name______Relationship

Address

Street City State Zip

Phone______How long have you known this person?

2.  Name______Relationship

Address

Street City State Zip

Phone______How long have you known this person?

3.  Name______Relationship

Address

Street City State Zip

Phone______How long have you known this person?

I authorize I-SS to contact the references I have listed.

______

Signature Date

Section 3: Background Check Information and Consent

BACKGROUND CHECK RELEASE AUTHORIZATION

In consideration of my application to volunteer, I authorize Iredell-Statesville Schools by and through North Carolina Administration of the Clerk of Courts and/or by and through a selected agency or source to verify all data given by me on application, related papers or oral interviews. I understand a thorough investigation may be conducted which may include, but not be limited to criminal history and motor vehicle driving record. I state that the information provided by me on my application is accurate and I agree that if any information therein is found to be false at any time, my application may be discarded. I understand that the information requested below regarding sex, race and date of birth are for the sole purpose of gathering the above information accurately and will not be used to discriminate against me in violation of the law. A facsimile (fax) or photocopy of this authorization shall be as valid as the original.

______**

Applicant’s Full Name (Please Print) Social Security Number

______

Maiden name or other names used Date of Birth Race Sex

______

Driver License Number/ State issued Applicant’s Signature Date

**A background check is not able to be completed without a Social Security Number. You may call the Human Resources Department of Iredell-Statesville Schools (704) 924-2053 and provide this information by phone if you prefer.

Do you plan on transporting students? ______

If yes, please provide a copy of your driver’s license and current insurance information.

Is this an overnight field trip? Yes______No______

Have you chaperoned before? Yes ______No______

Iredell-Statesville Schools maintains certain records on volunteers. In accordance with Section 115C-209.1 of the North Carolina General Statutes, those records are not public records and shall not be open to inspection, except in accordance with that law. A copy of this law can be seen on the I-SS website (www.iss.k12.nc.us.).

***For Office Use Only*** / Send Profile Form(s) and school check through courier to Race Street Office, Attn: Human Resources
SSN Scan______
Alias______
NC______
OOS______
Special instruction needed______
______/ Comments/Approval:

Rev. 8.4.17